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In Home Day Care Application

All questions must be answered in full. Application must be signed and dated by the applicant.

|Applicant’s Name       |Agent       |

|      |      |

|Applicant Mailing Address       |Applicant’s Phone Number       |

|      | |

|      | |

| |Web Address       |

| |Inspection Contact       |

|Proposed Policy Period       to       |Phone Number for Inspection Contact       |

|Applicant is Individual Partnership Corporation Joint Venture Other       |

|      |

|Location #1       |

|Location #2       |

|Location #3       |

Premises Information

|ARE THERE ANY OTHER BUSINESSES OPERATED FROM THESE PREMISES? YES NO |

|DESCRIBE THE BUILDING, AGE, CONSTRUCTION, # OF STORIES, ETC.       |

|ANY COOKING DONE ON PREMISES WHEN CHILDREN ARE PRESENT? YES NO |

|If so, what safety precautions are taken to avoid injury to children?       |

|Indicate what safety equipment is located on premises: |

|Smoke Detectors |

|Fire Extinguishers |

|Sprinklers |

| |

|Fire Alarm |

|Child Safety Equipment |

|Other       |

| |

|Have premises been inspected for compliance with building codes and health standards? Yes No |

|Any prior citations for health, safety or building code violations during the last 3 years? Yes No |

|If yes, explain:       |

|Is there an outdoor play area? Yes No |

|Is it fenced? Yes No |

|Describe play equipment and facilities:       |

|Are there any pets at this location? Yes No |

|If yes, describe type of pet and where it is kept.       |

|Is there a swimming pool or bathing beach on the premises? Yes No |

|If yes, describe:       |

|Any special classes taught? Yes No |

|If yes, describe:       |

|Do you offer off-premises activities: Yes No |

|If yes, describe:       |

Operations

|HOW LONG HAS APPLICANT BEEN IN BUSINESS?       |

|IS THE APPLICANT LICENSED/REGISTERED? YES NO |

|License/Registration Number:       |

|Attach a copy of the license or registration. |

|What Child Care Providers Association does applicant belong to?       |

|What is the maximum number of children permitted by license/registration?       |

|What is the maximum number of children on the premises at any one time?       |

|Are signed permission slips obtained from parents? Yes No |

|How long are they maintained?       |

|Indicate the number of children in each age group and the number attendants assigned to each age group, indicate full or part-time: |

|Age Group |# of Children |# of Attendants |Full Time (f/t) |

| | | |or |

| | | |Part Time (p/t) Care |

|0 to 24 months |     |     |      |

|25 months to 3 years |     |     |      |

|4 years to 6 years |     |     |      |

|Over 6 years |     |     |      |

|Are “special needs children” cared for? Yes No |

|If yes, describe:       |

|Is applicant staffed with qualified individuals to handle these children and their special needs? Yes No |

|Attach a list of all attendants, along with a description of their previous experience. |

|Is there a formalized employee screening and monitoring procedure in place? Yes No |

|Have you verified personal references and checked for any possible criminal records for your staff? Yes No |

|How often do you update your personnel records?       |

|Any licensed teachers on staff? Yes No |

|Any nurses or health care professionals on staff? Yes No |

|Any staff members under 18 years of age? Yes No |

|If yes, are they always supervised? Yes No |

|Has any member of your staff or household (including yourself), been sued, investigated, implicated, arrested, or convicted of any crime other than a |

|traffic violation? Yes No |

|If yes, provide details:       |

|Are you or any member of your staff under the care of any of the following: |

|Mental Health Clinic Psychiatrist Psychologist Alcohol/Drug Abuse Counseling Other       |

|If yes, explain:       |

|What days of the week do you operate? |

|Monday Tuesday Wednesday Thursday Friday Saturday Sunday |

|Daily hours of operation?       |

|Describe how injuries or illnesses are handled:       |

|      |

Operations (Continued)

|DOES APPLICANT MAINTAIN A RECORD OF MEDICAL INFORMATION (ALLERGIES, REGULAR MEDICATIONS, DOCTOR’S NAME AND PHONE NUMBER)? YES NO |

|Does applicant require parents to provide medical care releases? Yes No |

|Do you dispense medication? Yes No |

|Are all medications kept in a locked cabinet? Yes No |

|Attach a copy of the applicant’s rules and discipline policy. |

LIMITS – GENERAL LIABILITY (PER OCCURRENCE)

|GENERAL AGGREGATE (OTHER THAN PRODUCTS/COMPLETED OPERATIONS) |$       |

|PRODUCTS & COMPLETED OPERATIONS AGGREGATE |$       |

|PERSONAL & ADVERTISING INJURY (ANY ONE PERSON OR ORGANIZATION) |$       |

|EACH OCCURRENCE |$       |

|DAMAGE TO PREMISES RENTED TO YOU (ANY ONE PREMISES) |$       |

|MEDICAL EXPENSE (ANY ONE PERSON) |$       |

PRIOR CARRIER HISTORY & LOSS INFORMATION

|PRIOR CARRIERS (LAST THREE YEARS): |

|YEAR |CARRIER |POLICY NUMBER |LIMITS |PREMIUM |

|     |      |      |      |      |

|     |      |      |      |      |

|     |      |      |      |      |

|Loss History (Last Five Years) |

|Date of Loss |Type of Loss |Description of Loss |Amount Paid |Reserve |

|      |      |      |      |      |

| | |      | | |

|      |      |      |      |      |

| | |      | | |

|      |      |      |      |      |

| | |      | | |

|      |      |      |      |      |

| | |      | | |

|      |      |      |      |      |

| | |      | | |

|Has the applicant been cancelled or non-renewed in the last three years? Yes No |

|If yes, Explain.       |

|      |

|      |

This application shall not be binding unless and until confirmation by the Company or its duly appointed representatives has been given, and that a policy shall be issued and a payment shall be made, and then only as of the commencement date of said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured, and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the Insured.

IMPORTANT NOTICE

As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

FRAUD STATEMENT

To Insureds in the States of:

Alabama, Alaska, Arizona, California, Connecticut, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Maine, Massachusetts, Maryland, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, Nevada, North Carolina, North Dakota, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, West Virginia, Wisconsin, Wyoming:

NOTICE: In some states, any person who knowingly, and with the intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states. Penalties may include imprisonment, fines, or a denial of insurance benefits.

Arkansas

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado

It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

District of Columbia

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida

Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Louisiana

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties

New Mexico

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

New York

Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

Ohio

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania

Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime, and subjects such person to criminal and civil penalties.

Rhode Island

NOTICE: Under Rhode Island law, there is a criminal penalty for failure to disclose a conviction of arson. In some states, any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act, which is a crime in many states.

Virginia

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Washington

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

Producer’s Signature Date Applicant's Signature Date

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